Nina Pauli

The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer

Abstract Background. Trismus is a common symptom related to the treatment of head and neck (H&N) cancer. To date there are few prospective studies regarding the incidence of trismus and the patients’ experience of trismus in daily life activities. The aim of the study was to assess the incidence of trismus in H&N cancer patients and the impact on health-related quality of life (HRQL), by evaluating the patients before and after oncological treatment. Material and methods. We used the criteria for trismus of maximum interincisal opening (MIO) ≤ 35 mm and measured the patients at several occasions before and after treatment during one year. The patients answered the HRQL questionnaires EORTC QLQ C30, EORTC QLQ H&N 35, Gothenburg Trismus Questionnaire (GTQ) and the Hospital Anxiety and Depression Scale (HADS). Results. The incidence of trismus was 9% pre-treatment and 28% at the one-year follow-up post-treatment. The highest incidence, 38%, was found six months post-treatment. Patients with tumours of the tonsils were most prone to develop trismus. Patients with trismus reported greater HRQL impairments with regard to the GTQ domains; mouth opening (p < 0.001), jaw-related problems (p < 0.05), eating limitations (p < 0.05) and muscular tension (p < 0.001) six months post-treatment. EORTC QLQ H&N 35 scores indicated clinically significantly more problems with dry mouth, swallowing and pain for patients with trismus, 6–12 months post-treatment. Furthermore, all patients reported pain, anxiety and depression pre- and post-treatment. Conclusion. The incidence of trismus in patients with H&N cancer is non-negligible. Trismus severely impairs HRQL and negatively affects daily life activities in patients with H&N cancer. Further studies regarding symptomatic treatment of patients with trismus are highly warranted. The symptom-specific questionnaire GTQ is useful to identify the problems in this group of patients given it is responsive to showing change over time.

Exercise intervention for the treatment of trismus in head and neck cancer.

Abstract Background. The aim of this study was to investigate the impact of structured exercise with jaw mobilizing devices on trismus and its effect on trismus symptomatology and health-related quality of life (HRQL) in head and neck (H&N) cancer patients. Material and methods. Fifty patients with H&N cancer and trismus, i.e. maximum interincisal opening (MIO) ≤ 35 mm participated in a structured intervention program with jaw exercise. The patients in the intervention group underwent a 10-week exercise program with regular follow-up. A control group comprising of 50 patients with trismus and H&N cancer were matched to the intervention group according to gender, tumor location, tumor stage, comorbidity and age. HRQL and trismus-related symptoms were assessed. Results. The mean MIO improvement was 6.4 mm (4.8–8.0) and 0.7 (−0.3–1.7) mm in the intervention group and control group respectively, three months post-intervention commencement (p < 0.001). The intervention group demonstrated a statistically significant improvement in Role functioning, Social functioning and Global quality of life (EORTC QLQ C30) and in all Gothenburg Trismus Questionnaire (GTQ) domains, i.e. jaw-related problems (p < 0.001), eating limitation (p < 0.05) and muscular tension (p < 0.001). Conclusion. We found that a structured jaw exercise program was effective and improved the mouth opening capacity significantly. The objective effect on trismus (MIO) was also reflected in the patient-reported outcome questionnaires where the patients who underwent the structured exercise program after cancer treatment reported improvements in HRQL and less trismus-related symptoms compared to the control group.

Development and validation of the Gothenburg Trismus Questionnaire (GTQ)

OBJECTIVES To develop and validate a comprehensive, self-administered questionnaire for patients with limited ability to open the mouth, trismus. MATERIALS AND METHODS We derived the Gothenburg Trismus Questionnaire (GTQ) from empirical evidence in the medical literature and interviews with medical experts as well as patients. The draft version was tested in a pilot study (n=18). Patients with a maximal incisal opening (MIO) of ⩽35mm were included. The study comprised patients with benign jaw-related conditions (n=51), patients treated for head and neck (H&N) cancer (n=78) and an age- and gender-matched control group without trismus (n=129). RESULTS The GTQ instrument was well accepted by the patients, with satisfactory compliance and low rates of missing items. After item reduction, due to items not being conceptually relevant and/or low factor loadings, the GTQ demonstrated high internal consistency (Cronbachs alpha 0.72-0.90), good construct validity and known-group validity. CONCLUSION We developed a trismus-specific self-administered questionnaire, the GTQ, that showed good psychometric properties. We suggest this questionnaire, that has clear clinical relevance, to be adopted and used in clinical practice and in research, acting as a screening tool as well as an endpoint in intervention and jaw physiotherapy/rehabilitation studies.

Treating trismus: A prospective study on effect and compliance to jaw exercise therapy in head and neck cancer

Trismus after head and neck cancer is a symptom associated with pain and negatively affected health‐related quality of life. The purpose of this study was to compare two different jaw exercise devices and the compliance to exercise.

Risk structures for radiation-induced trismus in head and neck cancer

Treating head and neck cancer (HNC) is challenging as the tumors are located in a critical area where many essential functions originate. Amongst the late appearing side effects after radiotherapy (RT) for HNC, restricted mouth opening (trismus) occurs in more than one third of patients and have been described as persisting or even worsening five years after completed RT [1–3]. Trismus can lead to difficulties in eating, chewing, maintaining oral hygiene, and potentially to malnutrition and weight loss [2–6]. Irradiation of the temporomandibular joint (TM joint) and muscles of mastication, especially doses to the masseter and the pterygoid muscles, have been reported to be associated with radiation-induced trismus [7–11]. However, available data diverge as to which anatomical structure is more critical for trismus after RT in HNC. The aim of this prospective study was, therefore, to investigate if the use of both objectively and subjectively determined trismus can shed further light on this issue.

Exercise intervention for the treatment of trismus in head and neck cancer - a prospective two-year follow-up study.

Abstract Background This study aims to investigate the long-term effects of structured trismus intervention in patients with head and neck cancer (HNC) and trismus in terms of mouth opening, trismus-related symptoms and health-related quality of life (HRQL). Material and methods Fifty patients with HNC to receive radiotherapy ± chemotherapy were included in this prospective study along with a matched control group. The intervention group received a 10-week structured exercise with a jaw mobilizing device (TheraBite® jaw device or Engström device). Patients were assessed before and after trismus exercise intervention and at a two-year follow-up. Primary endpoint was maximum interincisal opening (MIO) and secondary endpoints included trismus-related symptoms and HRQL assessed with patient-reported outcome (PRO)-instruments [Gothenburg Trismus Questionnaire (GTQ), European Organization for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) and the related HNC-specific module the EORTC Head & Neck Questionnaire (EORTC QLQ-H&N35)]. Results The intervention group had a higher MIO at the two-year follow-up compared to the control group (40.5 mm and 34.3 mm, respectively), which was statistically significant. The intervention group also reported less jaw-related problems according to the GTQ and higher functioning as measured by EORTC QLQ-C30 and QLQ-H&N35 compared to the control group. Conclusion A positive persistent effect of exercise intervention for trismus in HNC patients was found with regard to MIO, trismus-related symptoms and HRQL. Exercise intervention is important in long-term treatment of radiation-induced trismus in HNC patients. The trismus-specific questionnaire, GTQ, is a valuable tool for observing and evaluating trismus over time.

Temporal patterns of patient-reported trismus and associated mouth-opening distances in radiotherapy for head and neck cancer: A prospective cohort study

To identify temporal patterns of patient‐reported trismus during the first year post‐radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs).

The Effect of Jaw Exercise on Trismus in Head and Neck Cancer Patients

Objectives: Trismus is a symptom that impacts daily life activities and adversely affects patient health-related quality of life (HRQL). Radiation-induced fibrosis is probably one of the most important etiological factors to trismus in head and neck cancer (HNC). The aim of this randomized prospective study was to compare 2 different jaw exercise devices, regarding improvement in mouth opening (MIO) and patient-reported symptoms in HNC patients with trismus. Methods: The 50 study patients were enrolled in a 10-week structured MIO training program and randomized to training with either TheraBite® device or Engström jaw device. The patients were regularly assessed by an oral surgeon and answered different questionnaires (ie, EORTC HN35 and the Gothenburg Trismus Questionnaire [GTQ])). Results: Both groups improved their MIO, 7.2 mm (22.9%) and 5.5 mm (17.6%) for TheraBite® and Engström, respectively. The largest increase in MIO was seen during the first 4 weeks of exercise. After the exercise periods 84% in the TheraBite® group (n = 21) and 60% in the Engström group (n = 15) no longer fulfilled the trismus criteria. A statistically significant improvement regarding trismus related symptoms in both groups with less pain, jaw-related problems, and eating limitations after the exercise period was found (P < .05 and P < .01). Conclusions: Structured intervention with a jaw exercise device improved the mouth opening capacity with less trismus-related symptoms in HNC patients. No statistically significant differences between the different devices were found. We suggest a feasible exercise program for radiation-induced trismus in HNC patients.